INCREASING RN GRADUATES IN TEXAS

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Task Fo

rcetoIncrease RN Gradu ates

InTe xas

The following report is the Task Force's report to the Coordinating Board.

The Coordinating Board used this study as the basis for its own report to the 80th Texas Legislature.

The report submitted to the Legislature was a more consolidated version of the Task Force's study, excluding much of the

background information and including a small number of substantive differences A reader may wish to review both reports in order to fully understand the work of the

Task Force and the focus of the

recommendations presented to the Texas Legislature on nursing student retention

issues.

January 2007

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INCREASING RN GRADUATES IN TEXAS

A Report to the 79 ^th Legislature

by

The Task Force to Increase RN Graduates in Texas

October 2006

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TABLE OF CONTENTS

Executive Summary 5

Background 10

Origin and Scope of Study 11

Study Methodology 12

Overview of Nursing Education in Texas 12

Summary of Key Findings 23

Graduation Rates of Nursing Programs 24

Practices That Affect Student Success 27

Conclusions and Recommendations 33

Strategies and Action Plans 33

Areas for Future Study 35

List of Sources 37

Appendices

Appendix A Legislative Charge 38

Appendix B Regional Map 39

Appendix C Task Force Membership 40

Appendix D Program Administrator Survey 42

Appendix E Faculty Survey 46

Appendix F Student Survey 51

Appendix G Survey Results 56

Appendix H List of Institutions 84

Appendix I Acknowledgements 86

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List of Tables

Table 1: Initial RN Licensure Programs by Type of Nursing Degree 11 Table 2: 2005 ADN and BSN Graduates, State Population, and

Total Baccalaureate Graduates 15

Table 3: 2005 Median Salaries for Full-time Nursing Faculty

At Public Institutions 22

Table 4: Statewide Graduation and Persistence Rates For

Initial RN Licensure Programs 25

Table 5: 2005 Graduation and Persistence Rate of Programs Surveyed 26

Table 6: Number of Survey Respondents 27

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List of Figures

Figure 1: Public and Independent Institutions in Texas 14 Figure 2: Qualified Applications to

RN Licensure Programs in Texas (1997-2005) 15 Figure 3: Total First-Year Entering Enrollment in

RN Licensure Programs (1997-2005) 16

Figure 4: Total Graduates from

Initial RN Licensure Programs (1997-2005) 17 Figure 5: Average Total Enrollment and Average Faculty FTEs

in All Initial RN Licensure Programs in Texas (2001-2005) 18 Figure 6: All Nursing Faculty by Age (2004) 19 Figure 7: Number of Students Enrolled in Graduate Nursing

Programs at Public Institutions (1996-2005) 20 Figure 8: Number of Graduates from Master's and Doctoral

Nursing Programs at Public Institutions (1996-2005) 21

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Executive Summary

The 79^th Legislature directed the Texas Higher Education Coordinating Board (THECB) to identify, develop, and study strategies for increasing graduation rates from initial licensure registered nurse (RN) programs in the state and determine which of those strategies are effective. This report is the THECB’s response to that directive.

The THECB formed a nine-member Task Force to study the issue and examine data available from the THECB, the Board of Nurse Examiners for the State of Texas, the Texas Center for Workforce Studies, nursing programs in Texas, and published literature. The Task Force’s major findings are:

1. To meet the increased demand for new RNs means that nursing programs need to increase the total number of full-time-equivalent (FTE) faculty positions by 54% by 2010.

2. 70% of faculty currently employed in nursing programs (about 1,250 faculty) will reach retirement age within the next 3 to 15 years.

3. Only about 31 of the 634 nurses who annually complete graduate degree programs (master’s or doctoral) are prepared to assume faculty roles in nursing programs. The majority of graduates are prepared to assume advanced practice roles

4. Compensation packages (primarily salaries) in clinical and private-sector settings lure current and potential nurse educators away from teaching.

5. To maintain enrollments, nursing programs are employing advanced practice nurses. These nurses have no formal preparation in the

instructional competencies needed by faculty and typically teach part-time.

6. During the past 5 years, full-time faculty positions have decreased by 9.5% while part-time positions increased 32%. To maintain program quality, full-time faculty have taken on the additional work of updating the curriculum, integrating technology, and ensuring that students receive the academic services they need to be successful. As they can, they mentor part-time faculty.

7. To meet the projected demand for RNs, the number of graduates from initial RN licensure programs must increase by 50% by 2010.

8. The pool of qualified applications for admission into nursing programs is three to four times larger than the number of seats available in nursing programs

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9. In 2005, nursing programs graduated 6,399 students eligible for initial licensure as RNs. This was a 13% increase over the number graduating in 2004.

10. In 2005, the graduation and persistence rate for nursing programs was 69%.

11. The major barrier to successful completion for students in nursing programs is financial.

12. Even though the majority of students receive some form of financial aid (to cover tuition and fee costs), most need to be employed to cover living expenses, transportation, child care costs and to have health benefits for themselves and their families.

Conclusions

A substantial investment in preparing, recruiting, and retaining faculty in nursing programs is needed NOW. Without large and significant increases in the number of faculty to teach in nursing programs the shortage of new RNs will sharply increase.

Without adequate numbers of nurses to care for healthy, ill, and recovering Texans the consequences are predicable. More Texans will die, more will suffer unnecessarily, more will go without care, more will seek expensive medical interventions and the cost of care will continue to escalate.

Nursing programs can probably make small increases in the number of graduates by streamlining administrative processes (regionalizing admission processes); formalizing assessment and referral programs (screening students early and often to identify those at risk for not completing the program, and providing or referring to appropriate help);

providing resources to expand instructional capabilities (simulation centers; on-line courses); and creating financial aid packages that meet students’ monetary needs (developing cooperative “learn-earn” programs with healthcare employers). Each of these strategies requires investment of funds and faculty time and effort with a relatively low return on investment. Individually and collectively, they are insufficient to achieve the 50% increase in graduates from RN initial licensure programs needed to meet demand.

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ACTION TO BE TAKEN BY . . . . STRATEGIES

(High priority strategies are shaded)

Legislature THECB Educational Institutions BNE TCNWS Health Care Industry

1. Increase the number of Nursing Faculty A. Increase salaries of nursing program faculty

so that they are competitive with those in the healthcare industry.

1) For all newly appointed nursing faculty set starting salaries for Master’s prepared faculty at a minimum of

$50,000.00 and faculty with a PhD a starting salary of $65,000.00 for a 9- month contract.

X X X

2) For all faculty currently employed in nursing programs who are not making the above minimums, increase their salary to the above minimum.

X X X

B. Fund stipend programs for graduate study in nursing education to students who agree to full-time study and a post-graduation 3 year commitment to be employed as a faculty member in a nursing program in Texas. 1^st year stipend level will be $40,000.00 with a 3% increase for each subsequent year up to 3 years. Fund 50 during the Biennium.

X X X

C. For faculty who are not prepared in the Nurse Educator Role, fund 15 semester credit hours of coursework in: Teaching, Evaluation, Curriculum Design,

Methodologies, and related courses. These courses may be taken through regular academic programs or online programs through such courses provided by the National League of Nurses (NLN) and the Southern Regional Education Board (SREB).

With an approximate fee of $700.00 per course (3 semester credit hours). For the biennium fund 400 persons.

X X X

D. In addition to the Professional Nursing Shortage Reduction Program, fund programs for increases in graduates with preparation in the nurse educator role

X X X

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2. Increase the number of Graduates

A. Streamline administrative processes:

1) Ensure that every nursing program seat

is filled with the most qualified student.

X X

2) Establish a regional admission center(s)

X X X

3) Develop a standardized minimum data set for admission variables for

application to all nursing programs in Texas.

X X X

4) Establish a standardized minimum data set that supports evaluation and best practices in nursing programs.

X X X

5) Establish a standardized program

completion formula.

X X X

B. Target as the benchmark for excellence in nursing programs, a program completion rate of 85%

1) Identify best practices for identifying students at-risk for not completing the program.

X

2) Identify best practices for helping those who have been identified for being at-risk to stay in the program and to graduate.

X

3) Conduct an annual student success conference to showcase and highlight best practices.

X X

4) Publicly recognize nursing programs that

achieve the standard of excellence.

X

5) Establish a mechanism for funding education studies on interventions that enhance student success.

X

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2. Increase the number of Graduates

C. Provide resources to expand instructional capabilities

1) Have yearly regional workshops to highlight innovative instructional strategies in nursing education.

X X

2) Continue to develop new, accelerated,

and alternate entry degree options.

X X X

3) Promote innovation in nursing education through the regionalization of common instructional functions, interdisciplinary instruction, pooled or shared faculty, and new clinical instruction models to

maximize the use of existing resources and faculty.

X X X

4) Establish a task force to study ways in which the healthcare industry can partner with nursing programs to increase the number of RN Graduates in the workforce.

X X X X X

D. Enhance and expand financial aid packages

1) Establish a task force to develop

financial aid packages that cover tuition and fees, living expenses, and

healthcare coverage for students.

X X X X X

2) Develop cooperative “learn-earn”

programs between nursing programs and the healthcare industry.

X X X

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Background

Nurses are frequently the most visible health care practitioners in a hospital, school, home, or long-term care facility. Registered nurses (RNs) constitute the largest health care occupation, holding 2.3 million jobs in the United States. According to the Board of Nurse Examiners (BNE) Texas has 149,948 RNs residing and practicing in the state as of September 2006. Texas RNs are mostly female (91%) and white (75%). They have a median age of 47 and the median age is increasing at a rate reported to be more than twice that of all other occupations. Approximately 64% of the state’s RNs work in

hospitals, home health care settings (5%), or physicians’ offices (5%).

In recent years, Texas, like many states, has experienced a well-publicized nursing shortage. Contributing factors impacting the nursing shortage (both state and nationally) include:

• Enrollment in nursing programs is not growing fast enough to meet the projected demand for nurses over the next ten years.

According to a 2002 report by the Bureau of Health Professions (BHPr), to meet projected demand, the current supply of nurses in the United States would have to increase by 57% by 2010.

The same report projects that by the year 2010, Texas will be short 25,000

nurses. By the year 2020, Texas will be short 52,000 nurses. Supply is expected to grow by 26% (from 2000 to 2020).

Based on BHPr figures, in 2010 Texas will need to graduate 10,072 new RNs to keep up with demand; a 57% growth.

• A shortage of nursing school faculty is restricting nursing program enrollments.

According to the American Association of Colleges of Nursing’s (AACN) report on 2005-2006 Enrollment and Graduations in Baccalaureate and Graduate

Programs in Nursing, 32,617 qualified applicants to entry level baccalaureate programs were not accepted in 2005 (based on responses from 432 schools).

Almost three quarters (73.5%) of the nursing schools responding to the 2005 survey pointed to faculty shortages as a reason for not accepting all qualified applicants into entry-level nursing programs.

According to a BNE report, data for years 2001 through 2005 indicate, on average, 1 faculty member for every 3 to 4 graduates. To graduate 9,717 new RNs by 2010, Texas will need to increase faculty positions by 54%.

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• With fewer new nurses entering the profession, the average age of the RN is climbing.

• The total population of registered nurses is growing at a slow rate.

• Changing demographics signal a need for more nurses to care for our aging population.

• Job burnout and dissatisfaction are driving nurses to leave the profession.

In response to the current and projected need for RNs, the THECB has determined that increasing the number of RN graduates is of sufficient importance to make it a specific target for success in Closing the Gaps by 2015: The Texas Higher Education Plan. It also published the report, Increasing Capacity and Efficiency in Programs Leading to Initial RN Licensure in Texas in July 2004 which examined the state’s ability to produce enough nurses to respond to the state’s nursing shortage. From that report and others produced by Texas Center for Nurse Workforce Studies (TCNWS), public officials obtained more information about the complex issues surrounding the supply of, and demand for, nurses in Texas.

In recent years, several legislative initiatives such as the Dramatic Enrollment Growth Fund and the Professional Nursing Shortage Reduction Program have provided

incentives for nursing programs to increase their enrollment capacity. In the short-term, nursing programs have responded to this new source of funding by increasing total enrollments by 28% in the last four years. However, evidence now shows that programs have reached capacity given the limited number of new and replacement faculty available to teach in initial licensure program.

To meet the projected demand for RNs to care for the citizens of Texas, not only must enrollment capacity continue to expand, but efforts must also be directed to insure that qualified students admitted to nursing programs across the state, complete these programs in a timely, efficient manner, and are prepared to pass the state licensing exam so they may enter the RN workforce.

Origin and Scope of the Study

Senate Bill 132 (79^th Legislature) directed the THECB to identify, develop, and study strategies for increasing graduation rates from initial RN licensure programs, and to recommend strategies for increasing graduation rates in these programs. The charge is included as Appendix A.

To defray the costs of that effort, the Board committed Nursing Innovation Grant Program (NIGP) funds to support the study. As part of that commitment, the Board

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coordinate and lead data collection efforts, analyses, and implementation of

recommendations. The Task Force to Increase RN Graduates in Texas (Task Force), as it came to be known, also included representatives of the Texas State Department of Health’s Texas Center for Nursing Workforce Studies (TCNWS), the Board of Nurse Examiners for the State of Texas (BNE), Texas Nurses Association (TNA), and the THECB. Appendix C lists the members of the Task Force.

The scope of the study was limited to “initial licensure nursing programs” which are defined as “Diploma, Associate degree (ADN), and Baccalaureate degree (BSN) programs that prepare students to take the national licensure exam to become

registered nurses.” Because there are only two diploma programs in the state, both of which are private programs, they were not included in this study.

Study Methodology

The Task Force’s work encompassed three major activities. The first activity was to update the 2004 report, Increasing Capacity and Efficiency in Programs Leading to Initial RN Licensure in Texas, to make it more relevant to the objective of this study.

The second activity was to answer the question: “What are ‘program completion’ rates of initial RN licensure nursing programs?” To answer the question, the Task Force collected student enrollment data from the nursing programs and compared the data against THECB student records to calculate “on-time” program completion rates and persistence rates. The student data were also used to look at the impact of financial aid on student success and other student demographics. The results of that activity are included in the section “Graduation Rates of Nursing Programs” (p.24).

The third activity was an attempt to answer the question: “What are the characteristics and practices of students, faculty and administrators in initial RN licensure programs that affect student success?” To answer the question, the Task Force collected data from questionnaires distributed to program administrators, faculty teaching in, and students graduating from, initial licensure programs. The survey instruments and summaries of responses from each surveyed group are included in Appendices D, E, and F. The results of that activity are included in the section “Practices that Affect Student Success” (p. 27).

As a result of these activities, the Task Force formed conclusions and recommendations for implementing strategies to improve student success in initial RN licensure

programs. That information is included in the section, “Conclusions and Recommendations” (p. 33).

An Overview of Nursing Education in Texas

The majority of initial licensure programs consist of two “tiers” in that a student takes a minimum of one to two years of general academic or non-professional courses, and during that time completes a separate application to the “nursing program.” It then

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takes a minimum of two years to complete the nursing course sequence required for graduation and initial licensure. Because of the sequential nature of nursing courses, students can only begin the nursing program in a certain term, and must complete the courses as scheduled in subsequent semesters. This leaves virtually no opportunity for part-time study, and if a student has to drop out of the sequence due to academic, personal, or family-related reasons, it usually takes a minimum of one year to be

“readmitted” to the sequence, and that is usually on a “space available” basis.

The large majority of initial licensure programs also incorporate a “mobility” track for Licensed Vocational Nurses (LVNs) seeking initial RN licensure. These “tracks” usually include a “bridge” course which upon completion, gives “credit” for a specified number of initial licensure courses, and then the LVN-transition student becomes a part of the initial licensure student cohort completing the remaining courses. With an estimated 61,581 LVNs residing in the state, LVN-RN transition options would appear to be a significant way to increase the number of RN graduates. However, this mobility option has been limited, in large part due to the lack of qualified faculty.

Another mobility option has recently become available in a number of universities and academic health science centers. This normally “accelerated” option targets

baccalaureate graduates in another discipline who are interested in obtaining initial RN licensure. Again, this seems an optimum cohort from which to increase the number of RNs in the state, however the expansion of these accelerated tracks is limited due to the lack of qualified faculty.

Types and Locations of Initial RN Licensure Programs

Texas has three major types of educational programs leading to initial RN licensure.

They are:

1. Diploma Programs – traditionally require three years of study at a single-purpose school. In Texas, the state’s two diploma programs are administered by

hospitals. Diploma programs were not included in this study.

2. Associate Degree Programs (ADN) – previously referred to as “two year nursing programs” now traditionally require one year of academics (non-professional courses) and two years of nursing courses. The vast majority of the state’s associate degree programs are located in community colleges.

3. Baccalaureate Degree Programs (BSN) – traditionally require four years of study. The nursing curricula usually take place during the last two years at a university, or academic health science center.

Table 1 gives information about the number of each type of program and the percentage or students enrolled and graduating from them. Figure 1 shows the distribution of these initial RN licensure programs in Texas as of May, 2006.

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Table 1: Initial RN Licensure Programs* by Type of Nursing Degree

Type of Degree

Number of Programs*

% of Total 2005 Enrollment

% of Total 2005 Graduates

Diploma 2 2% 3%

ADN 56 55% 62%

BSN 26 43% 36%

Universities 22 35% 26%

Health-related Institutions 4 8% 10%

TOTAL 84 100% 100%

Source: Board of Nurse Examiners for the State of Texas

*Number of programs – represents higher education institutions or hospitals that are approved by the BNE to offer a program leading to initial RN licensure as of May 2006

Of the 84 programs included in Table 1, 72 represent nursing programs offered at public institutions. Of these programs offered at public institutions, 54 are ADN programs; 18 are BSN programs; and none are Diploma programs. Appendix H lists the institutions offering the nursing programs.

Figure 1: Public and Independent Institutions in Texas

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Applications

The state’s nursing programs have been successful in attracting qualified applicants.

As shown in Figure 2, applications increased by 135% from 1997 to 2005 and increased by 94% since 2001. While it is uncertain how many of the applications reported in 2005 are duplicates (multiple applications from the same person), a statewide study of 2003 application records found that most nursing applicants are likely to apply to one or more programs in their immediate area. This trend is consistent with other demographic information that shows that nursing students are significantly older than the average college student and often have family and work commitments that tie them to a specific geographic area.

Figure 2: Qualified Applications to RN Licensure Programs* in Texas (1997-2005)

9,504 6,544 9,610

8,004

11,646

16,048

22,592

14,060

7,322 5,324

6,723

8,532

4,324 2,680

2,887 0 4,000 8,000 12,000 16,000 20,000 24,000

1997 1998 1999 2000 2001 2002 2003 2004 2005

All RN Programs Diploma & ADN Programs BSN Programs

Admissions

The number of students admitted to, and enrolled in, the nursing course sequence of an initial licensure program increased 94% from 1997 to 2005. Diploma and ADN

programs, which represent 62% of the state’s first-year enrollments, increased by 78%

while BSN programs increased by 128%.

Enrollments have increased as the number of qualified applications have increased but not at the same rate. Nursing programs enrolled a greater percentage of enrollees to applications each year until 2003, when the percentage began to decline. By 2005, only 39% of applicants were enrolled – a ten-year low. While the 2005 figure may be

affected by the increasing number of duplicate applications, the trend suggests that factors other than the applicant pool are restricting enrollments.

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Figure 3: Total First-Year Entering Enrollment in RN Licensure Programs (1997-2005)

8,913 8,585

6,967

4,087 4,582

5,550 5,181

4,333

2,653 3,111

3,363 3,404

2,634 1,434

1,471 0 2,000 4,000 6,000 8,000 10,000

1997 1998 1999 2000 2001 2002 2003 2004 2005

All RN Programs Diploma & ADN Programs BSN Programs

Despite large increases in the number of persons applying for admission, nursing programs have limited capacity to admit them. For the vast majority of initial licensure programs, the number of clinical groups that can be accommodated, determines how many students can be admitted because of the BNE-mandated ratio of a maximum of 10 students per faculty member in a clinical group. For example, if a program sets an admission limit of 100, they will have, at a minimum, 10 clinical groups, each of which must be supervised by a faculty member. In 2005, lack of budgeted faculty and lack of qualified faculty were the most frequently stated reasons that nursing programs were unable to admit more qualified applicants. Another problem that has been identified by directors of initial licensure programs, is when a program fills all available seats, there is no way to “refer” qualified applicants that were unable to be admitted, to other initial licensure programs that may have openings as there is no “centralized” data base to obtain this information. To complicate the situation, a qualified student who could not be admitted to a specific program because of seat unavailability may be able to find another program with openings, and yet may not meet the admission requirements of that program in a timely manner. As a result, there were a total of 260 vacant seats across nursing programs in 2005. While representing only 3% of the total number of available seats in programs, having access to a centralized data base of vacancies and admission requirements of the various programs, could decrease the number of vacant seats.

Graduates

After a decline in nursing graduates (program completers) from 1997 to 2001, nursing programs began showing an increase in graduates beginning in 2002. The number of graduates has increased by 41% from 2001 to 2005. Diploma and ADN program graduates increased 46% from 2001 to 2005 as compared to BSN program graduates that increased 34%.

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Figure 4: Total Graduates from Initial RN Licensure Programs (1997-2005)

6,399 5,674

5,303 4,609

4,531 4,615

5,042 5,156 5,206

4,130 3,428

2,832 3,371

3,250

2,269 1,875

1,699 1,671

1,956

0 1,000 2,000 3,000 4,000 5,000 6,000 7,000

1997 1998 1999 2000 2001 2002 2003 2004 2005

All Initial RN Programs Diploma & ADN Programs BSN Programs

The ethnic composition of ADN and BSN graduates mirrors that of all 2005

baccalaureate graduates in the state. Despite efforts to attract men to nursing, the vast majority of nursing students continue to be female.

Table 2: 2005 ADN and BSN Graduates, State Population, and Total Baccalaureate Graduates

2005 ADN and BSN Graduates

2005 State Population

2005 Baccalaureate Graduates

Male 14% 50% 42%

Female 86% 50% 58%

White 61% 48% 61%

Hispanic 21% 35% 21%

Black 10% 12% 8%

Asian 5% 1% 6%

Other /

Unknown 3% 4% 4%

Sources:

1) Graduates: Texas Higher Education Coordinating Board;

2) Population: U.S. Census Bureau;

3) Baccalaureate Graduates: Texas Higher Education Coordinating Board Source: Texas Higher Education Coordinating Board

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168

201 203 208

16 17 17 18 19

184

0 50 100 150 200 250

2001 2002 2003 2004 2005

Average Total Enrollment Average Faculty FTE's

enrollments and graduations from under-represented groups. From 1997 to 2005, Hispanic graduates increased 62%.

Nursing Faculty Characteristics

The number and characteristics of faculty teaching in nursing programs is a major factor in determining enrollment capacity and may also be an indication of the quality of

instruction. In 2005, there were 1,579 FTE faculty employed in initial licensure programs, a 13% increase from 2004.

Over a five-year period, the average class size of initial RN licensure programs has increased by 22% while faculty FTEs have increased by 19%. These disparities probably cannot continue to increase without affecting educational quality.

Figure 5: Average Total Enrollment and Average Faculty FTEs in All Initial RN Licensure Programs in Texas (2001-2005)

The percentage of full-time faculty positions has decreased 9.5% in the last five years while the percentage of part-time faculty positions has increased by 31.8% during the same period. According to a National League for Nursing study (2006), the majority of baccalaureate and higher degree programs and almost half of associate degree

programs reported hiring part-timers as their primary strategy to compensate for unfilled, budgeted, full-time positions. While this approach allows for greater flexibility, often part-time faculty are not an integral part of the design, implementation, and

evaluation of the overall program. And, because they typically hold other positions, they are not as available to students as full-time faculty are, and frequently have conflicts between the time commitments required by their teaching and other positions. This trend raises concerns about ensuring the quality of instruction in these programs.

As indicated in Figure 6, in 2004, 70% of 1,800 nursing faculty were 50 years of age or older.

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60 years of age or older

22%

Less than 50 years of age

30%

50-59 years of age 48%

70% of nursing faculty are over 50 years of age

Figure 6: All Nursing Faculty* by Age (2004)

*Includes faculty participating in all levels of nursing education, including those in initial RN licensure programs.

Source: Texas Center for Nursing Workforce Studies

With approximately 1,250 faculty expected to retire within the next 5-15 years, the nursing programs will have a significant challenge to replace these faculty and continue to maintain existing capacity. Losing these veteran faculty members also suggests that nursing programs will have an even more difficult challenge in meeting targets for

increasing capacity in these programs unless incentives are in place to recruit faculty and streamline the hiring and training processes. To meet the increased demand for new RNs means that nursing programs need to increase the total number of FTE faculty positions by 54% by 2010.

Potential Faculty

In anticipation of the need for approximately 1,250 new faculty to replace retiring faculty in initial RN licensure programs, the Task Force examined the state’s potential to

produce them from its own graduate programs.

The number of students in graduate nursing programs has increased by 35% from 1996 to 2005, with the 2005 totals representing a 10-year high. Enrollments in master’s level programs increased 34% and doctoral programs increased 46% during this ten-year period.

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Figure 7: Number of Students Enrolled in

Graduate Nursing Programs at Public Institutions (1996-2005)

Source: Texas Higher Education Coordinating Board

Nursing education, a specialization that could more directly indicate student interest in becoming nursing faculty, represented only 5% of students enrolled in master’s level programs in 2005. In contrast, advanced practice-based specialists, including clinical nurse specialists, nurse practitioners, nurse midwives and nurse anesthetists,

represented 95% (583 students) of the students enrolled in master’s level programs in 2005. Student interest in these other specializations most likely reflects the perceived status of those practitioners within nursing, the demand for advanced practice nurses, and the salaries they are paid.

The number of graduates from master’s and doctoral degree programs has increased 11% from 2001 to 2005. The number of graduates from master’s degree programs has increased by only 15% from 2001 to 2005 and the number of graduates from doctoral programs has decreased 67% during that period.

1,865 1,836 1,823

2,278

2,757

220 210 229 302 322

2,085 2,046 2,052

2,580

3,079

0 500 1,000 1,500 2,000 2,500 3,000 3,500

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Year

Number of Graduate Students

Master's Enrollees Doctoral Enrollees Total Graduate Student Enrollees

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Figure 8: Number of Graduates from Master's and Doctoral Nursing Programs at Public Institutions (1996-2005)

610 531

463

525 509

24 24

42 27 40

571

487

634 567

536

0 100 200 300 400 500 600 700

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Master's Graduates Doctoral Graduates Total Graduates

The trend data suggest that nursing programs will have a difficult time recruiting potential faculty from the large percentage of master’s degree graduates who are

choosing advanced practice-based specialties. Furthermore, if programs are successful in finding faculty from those graduates in advanced practice-based specialties, the new hires are less likely to have the instructional skills needed to teach students. Providing those basic skills will most likely add to the cost of the programs.

Faculty Salaries

As stated earlier in this report, only 5% of students enrolled in master’s level programs in 2005 were pursuing the nurse educator option. 95% of graduate master’s level students were pursuing an advanced practice based specialty, with the majority being nurse practitioner tracks. Student interest in this specialization most likely reflects the perceived status, demand, and salaries.

Data from the Labor Department and other sources show the average annual salaries of nurse practitioners in Texas ranging from $69,745 to $78,784 with a mean salary of

$73,150.

It is difficult to compare a 12 month salary of a nurse practitioner with a 9 month nurse educator salary. In particular because of the varying ranks in universities and the fact that the large majority of nurse educators are employed by community colleges. Table 3 shows the average budgeted faculty salary by assistant professor at public

universities in Texas.

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Table 3

Based on the assumption that a beginning nursing faculty member would most likely start at the bottom of a salary schedule (assistant professor) the mean 9 month salary would be $37,660.

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Summary of Key Findings

1. In recent years, the state’s nursing programs have substantially increased interest in nursing, enrolled more students, and graduated more of them.

Despite these increases, the number of new graduates does not meet the current demand for new nurses.

2. The pool of qualified applications for admission into nursing programs is three to four times larger than the number of seats available in the nursing

programs.

3. The number of faculty available to teach in nursing programs determines enrollment capacity.

4. Despite the increasing competitiveness for admission to nursing programs, in the Fall of 2005, 3% of available seats were unfilled suggesting that schools could do a better job of coordinating the admission process.

5. Over the past five years, the average class size of initial RN licensure

programs has increased by 24% while faculty FTEs have increased by 19%.

These disparities probably cannot continue to increase without affecting education quality and graduation rates.

6. The percentage of part-time faculty has increased in the last five years. As the number of part-time faculty has increased the number of full-time faculty has decreased. This trend raises potential problems with controlling the quality of instruction.

7. Approximately 1,250 faculty are over the age of 50 (70% percent): 22% are expected to retire within the next five years; 48%, within the next 5-15 years.

The large number of retirees presents significant challenges for nursing

programs to maintain their current capacity for initial RN licensure students let alone meet projected increases to meet workforce demand.

8. While the number of students in graduate nursing programs represents a 10- year high, only 5% are choosing nursing education as a specialty.

9. To meet the projected demand for new RNs the total number of FTE nurse faculty must be increased by 54% by 2010.

10. A beginning nursing faculty member would most likely start at the bottom of a salary schedule (assistant professor) the mean 9 month salary would be

$37,660 compared to that of annual nurse practitioner salary of $73,150.

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Graduation Rates of Nursing Programs

In January 2006, the THECB asked the state’s nursing programs to provide a list of the new students who enrolled in initial RN licensure programs in Spring 2003, Summer 2003, or Fall 2003. The list excluded any students who transferred from another nursing program or were readmitted to a program after earning nursing course credits prior to spring 2003. The lists submitted by the programs also excluded enrollees in part-time or alternate entry tracks. The THECB received student data from 68 of the 76 institutions (89% response rate) that admitted students during one or more of those three semesters in 2003. The two diploma programs and several programs at

independent institutions were not included in the analysis because the THECB did not collect student records for those institutions in 2003.

Once submitted, the names and Social Security numbers of the students were matched against the THECB’s database of student records and then tracked through academic year 2005. Through this process, the Board could generate program completion and persistence rates for this cohort of students for each of the five data collection regions, by type of degree program, by ethnicity of the student, and by students’ financial aid status. The cohort was also used to determine the median age of entering nursing students in these initial RN licensure programs.

Table 3 summarizes the graduation and persistence rates by data collection region, type of degree program, student ethnicity, and financial aid status.

From this cohort of students admitted to initial RN licensure programs in 2003, the Task Force determined:

• Approximately 56% of full-time students completed the nursing program on-time (within four to five semesters).

• Approximately 13% of the original 2003 student cohort that did not complete the program by summer 2005, were enrolled in the nursing programs in Fall 2005.

Data were not available at the time of publication to determine how many of those students would eventually complete their nursing programs.

• About 31% of the original 2003 student cohort did not complete the nursing program, and were no longer enrolled in the programs in Fall 2005.

• Programs in the South Texas region had a slightly better “on-time” completion and persistence rate than programs in the other regions; however, overall, completion and persistence rates were fairly consistent across all regions of the state.

• Health-related institutions had significantly higher completion rates. Community colleges had a higher “on-time” completion rate than universities, but the lowest persistence rate of the three types of institutions.

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Table 4: Statewide Graduation and Persistence Rates For Initial RN Licensure Programs

2003 Nursing Enrollees*

Graduates as of Summer 2005

"On-time"

Graduation Rate**

Non- Grads Enrolled in Fall 2005

"On-time"

Graduation

&

Persistence Rate ***

By Data Collection

Region

Region 1: West Texas 1,176 631 54% 186 69%

Region 2: South Texas 1,922 1,212 63% 205 74%

Region 3: Gulf Coast 1,657 864 52% 202 64%

Region 4: East Texas 1,059 566 53% 167 69%

Region 5: North Texas 1,880 1,070 57% 241 70%

Statewide 7,694 4,343 56% 1,001 69%

By Type of Institution

Community College 4,500 2,549 57% 386 65%

Health-related Institution 665 496 75% 54 83%

University 2,529 1,298 51% 561 74%

Total 7,694 4,343 56% 1,001 69%

By Ethnicity and Financial Status

White 3,995 2,701 68% 481 80%

Black 854 399 47% 156 65%

Hispanic 1,492 917 61% 200 75%

Asian 286 163 57% 54 76%

American Indian 48 33 69% 6 81%

International 148 86 58% 26 76%

Unknown 61 44 72% 8 85%

No Financial Aid 3,109 1,704 55% 328 65%

Received Financial Aid **** 4,344 2,639 61% 617 75%

Total 7,453 4,343 58% 945 71%

* “2003 Nursing Enrollees” are new students enrolled in the program for the first time in the spring, summer or fall semester of 2003.

** “On-time” Graduation Rate is the number of students in the original 2003 cohort who are reported as graduates by summer 2005, divided by the original “2003 Nursing Enrollees” cohort.

*** "On-time" Graduation & Persistence Rate *** is the number of students in the original 2003 cohort who are reported as graduates by summer 2005 plus the number of students who are reported as enrolled in the program in Fall 2005, divided by the original “2003 Nursing Enrollees” cohort.

**** “Received Financial Aid” represents students in the original 2003 cohort who received state financial aid during any one or more semesters in which they were enrolled in the nursing program.

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• “On-time" completion and persistence rates for White, Black, Hispanic, and Asian nursing students, varied by 15%: White students had the highest graduation and persistence rate at 80%; Black students, the lowest rate at 65%.

• Students who received state financial aid were more likely to complete on-time or persist in the programs than students who did not receive state financial aid.

Further analysis showed that students who received aid for two or more years were more likely to complete on-time or persist in the program (83%) than students who received aid for one year (62%).

In 2005, 24% of nursing programs included in the study had combined

graduate/persistence rate of at least 85%. A further breakdown is shown in table 4.

Table 5: 2005 Graduation and Persistence Rate of Programs Surveyed

Total Type of Institutions

Surveyed

Number of programs with at least an 85%

graduation/persistence rate

Total Percent of Graduates

Community Colleges 43 8 19%

Universities 21 5 24%

Health Related Institutions

4 3 75%

From this data, the Task Force also found that the median age of a new nursing student was significantly older (26 years old) than the average freshman at a community college (20 years old), junior at a university (21 years old) or health-related institution (24 years old). ADN program students were significantly older than BSN program students. The median age of a new ADN program student in most regions of the state was between 28 and 30 years.

• Despite growing competiveness for admission, it is estimated that only 70% of admitted students are likely to complete a nursing degree.

• Students who received financial aid over a period of more than one year had a significantly greater probability of completing the program than did students with one year of financial support.

• Nursing students are significantly older then their counterparts in other associate degree and baccalaureate degree programs. The age difference suggests that these students may have more family commitments and work-related issues than the average college student. It also suggests that there may be more financial demands, including child care, health care benefits, etc.

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Practices that Affect Student Success

To identify practices that affect student success in nursing programs, the Task Force designed surveys to be completed by program administrators, faculty teaching in initial licensure programs, and students graduating from initial licensure programs in Spring 2006. Copies of the surveys are included as Appendices D, E, and F.

Two questions asked of all respondents were: the degree of emphasis the program places on graduating on time, and the strategies they would advocate to increase

graduation rates. Information was sought from both faculty and students on obstacles to completing the nursing program, helpfulness of services to students in completing the nursing program, and demographic information about themselves. Faculty and

administrators provided information on approaches to identifying students at risk for not completing the program, obstacles to faculty in helping students complete the program, and success of interventions for students at risk for not graduating. Other information requested from program administrators included admission criteria most predictive of program completion, selection processes, use of exit interviews, support from local healthcare agencies, and program statistics. Other information requested from students included the importance of various people in helping them complete the program and reasons why they were successful when others were not.

In February and March 2006, the Task Force distributed administrator, faculty and student surveys to each ADN and BSN program in the state (See Appendix H) for names of the programs). All but 3 programs (2 community colleges and 1 university) provided student and faculty responses for a 96% program response rate.

Administrators from 65 programs responded (83% response rate). Administrator, faculty and student responses to each item on the surveys are detailed in Appendix G.

The number of program administrators, faculty and students who provided survey responses are indicated in Table 6. Demographically, they mirror the characteristics of students and faculty presented earlier in the report.

Table 6. Number of Survey Respondents

Type of Institution Number of Programs Administrators Faculty Students

Community College 47 43 774 2208

University 24 20 253 760

Health Science Center 4 2 35 168

Total 75 65 1062 3136

The Task force grouped the data from the responses of program administrators, faculty, and students into nine broad categories. Illustrative data associated with each category are described below.

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Admission Practices

Although nursing programs differ in the admission criteria that they think predict success in the program, almost all request the same information from applicants. Most use

Grade Point Averages (overall and pre-requisite courses) and some type of

standardized pre-entrance examination. BSN programs, and programs with graduation plus persistence rates of 85% or higher, are more likely than are ADN programs and programs with lower graduation plus persistence rates to think that applicant interviews are predictive of success.

Most nursing programs have a 2-tier applicant review/admission process: institutional and discipline/program. The discipline/program specific processes tend to be intensive and extensive and require both faculty and staff time and effort. Most use some form of point/weighting system to rank and select the best qualified applicants. Because of a lack of standardization of admission criteria between programs (e.g. some programs requiring interviews, entrance exams, etc. while others do not) qualified students who are not admitted to one program due to lack of seat availability may be unable to complete admission requirements to another program in a timely manner.

Program administrators and faculty suggested regionalized and/or shared admission

“centers” so as to place “the best qualified students” into nursing programs.

Financial support for students

Most students in nursing programs depend on scholarships and loan programs to finance their studies. Nursing students incur many more expenses than just tuition and fees. Nursing programs require a large number of specialized textbooks, uniforms, liability insurance, fees for criminal background checks, achievement testing, etc. Most students enrolled in nursing programs are employed to help finance their personal and family needs including living expenses, child care, and health benefits for themselves and their families.

Program administrators, faculty, and students agreed that students need an increase in financial support including more scholarships, grants, and loans and help in paying living expenses. The requirements for eligibility for financial aid often prevent needy students from getting it. For a large and growing number of students, the major barrier to staying in the program and graduating is the students’ need to work to finance their personal and family needs. A major reason for students dropping out of programs was not poor grades but the need to provide for their families, to deal with family issues and or illnesses. When a student drops out of a program for academic reasons, the root cause is often working too much which does not allow enough time for studying.

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Academic Support for Students

Most nursing programs have advising and academic services that use both staff and faculty time and effort.

Although there was some agreement across program administrators and faculty on factors that place students at risk for not graduating, almost no program claims to have a system to identify those at risk.

For students at risk, nursing programs provide different academic services. For

example, program administrators and faculty identified working with a faculty or nurse mentor and participation in study groups as interventions helpful to students at risk for not graduating. Faculty also identified supplementary classes/tutoring. However, programs tend not to have information about which of the offered services best help students to succeed.

All respondents agreed that faculty had workloads and student-to-teacher ratios that prevented faculty from being able to offer academic services much less evaluate them to see which worked best. Student-to-teacher ratios were higher among programs with graduation rates less than 85% as compared with that in programs with 85% or better graduation rates.

Program administrators and faculty suggested funding of academic support services (including test taking and time management programs), the development of programs to identify those at risk and provide services to those identified, and funding for teaching assistants/tutors as possible strategies for increasing student success.

Faculty Complement

Program administrators, faculty and students spoke to the need for more faculty to meet the current and projected need for more nurses in the workforce. Students spoke to the need for faculty who have the competencies needed for effective teaching. Students also recognized the need for higher salaries for teachers.

A second suggestion to increase the number of faculty was to give incentives for nurses to get master’s degrees. Administrators and faculty said that hiring advanced practice RN’s as faculty generally increases the number of part-time faculty (placing the burden of course responsibilities on full-time faculty) and requires that full-time and seasoned faculty provide extensive support in the roles and responsibilities of faculty (classroom teaching, clinical teaching, testing and evaluation, and other teaching competencies).

They suggest that master’s degree programs do more to prepare educators and that financial incentives be paid to those getting master’s degrees from programs that prepare nurse educators.

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Program Characteristics/Administration

Over 60% of all respondents indicated that there is only a moderate emphasis on students graduating on time. Program administrators and faculty at programs with an 85% or higher graduation plus persistence rate placed heavier emphasis on completing the nursing program on time than did faculty at programs with lower rates.

Nursing programs with an 85% or better graduation plus persistence rate were significantly less likely than schools with less than 85% graduation plus persistence rates to use local healthcare organization nurses as clinical preceptors.

Over 60% of nursing programs conduct exit interviews with students permanently leaving the school.

Students recommended smaller student to faculty ratios as “one method to increase student success.”

Each group of respondents pointed to some form of lengthening or shortening nursing programs. Examples of these suggestions include “more part-time study options,”

greater flexibility in course sequencing, “fast-track programs for second degree students”, “week-end only study”, and “eliminating programs with small numbers of graduates with redistribution of their funds to programs with larger numbers.”

Infrastructure needs

Program administrators, faculty, and students spoke to the need for expanding facilities and improving the kind and amount of teaching equipment. Funding of simulation centers and regional learning labs was suggested as one way to overcome the facilities and equipment problems as well as the shortage of clinical placement sites.

Public disclosure

Most graduating seniors thought that having information about a school of nursing’s NCLEX-RN pass rate would have influenced their decision on choice of program.

Faculty and students suggested that information about nursing, its challenges and rewards, be given to students in elementary school so that they could plan to develop the critical thinking and science and math skills needed for success in nursing

programs. As one faculty member pointed out “Fix/finalize School Finance Plan. Our students are ill prepared in critical thinking, math, science…Fix it.”

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Definition of outcome/program performance measures

When asked how the program computed completion rates, program administrators gave very different answers. Their answers reveal that there is no standard or uniform

formula for calculating completion rates.

Program administrators and faculty identified the need to use a standardized formula for computing this rate so that programs can be evaluated on how well they are responding to the need for more RNs. Not having such a formula makes it impossible to know where to look for best practices.

Teaching and Testing Strategies

Program administrators, faculty, and students suggested that smaller student to faculty ratios would increase the number of RNs graduates in Texas. Many suggested smaller ratios for clinical or field learning experiences and for classroom courses. They thought the best ratio for clinical learning experiences where a faculty member supervises students as they take care of patients should be limited to 6 to 1 rather than the current 10 to 1 ratio. Patients are sicker and their care more complex. Students need more time with the faculty member so that they can put into practice what they learned in the classroom. So that they can learn what they need to learn in the classroom, there should be only 30 students to each faculty member. Students pointed out that keeping student to faculty ratio smaller was “one method to increase student success.”

Simulation centers and use of simulation technology were identified as one way to help students develop the clinical competencies needed for safe practice and to ease the problem of finding adequate numbers and types of clinical learning experiences for students. Both faculty and students found nursing skills labs a good way to learn clinical skills but having more equipment and technology would help make it even better.

Faculty and students thought that computers and computer technology to support teaching helped students be successful. They thought that on-line and internet classes were helpful to their learning and could ease scheduling burdens.

Students suggested that fairer and more uniform performance/evaluation criteria would increase the number of RNs entering the workforce. The most frequently cited example dealt with students being required to pass the Heath Education Systems Incorporated (HESI) exit exam in order to graduate.

1. Persons entering nursing programs do not know how hard the programs are or how much study time is needed to pass the courses. They tend not to know differences between the types of programs nor how or where to get information